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RFI # 904:
5010 277-Entity Identif. code

Informal
Formal

Submitter

Elitsa Nedyalkova

Description

On page 139 from the 5010 276/277TR3 it is stated that element STC01-3 is required when an entity must be identified to further clarify the code message in STC01-2. An example is for that is when the code in STC01-2 is 16 - Claim/encounter has been forwarded to entity and the entity has to be identified.

My question is if a Blue Cross plan receives a claim and the claim is forwarded to another Blue Cross Plan for processing, , what is the best match from the Entity Identifier codes that can be use?

Response

DRAFT - The issue of identifying specific Entity Code use for varying business scenarios is not explicitly addressed in the 005010X212 Health Care Claim Status Request and Response. However, you are correct in that an Entity Code is required in STC01-3 whenever the status code in STC01-2 refers to an ‘Entity’.

Recommendation

The workgroup’s understanding of Blue Plan relationships is that while the claim may be ‘transferred internally’ to another Blue for processing, the two Blue Plans (Host and Home) are essentially working together as one Blue Plan and would not report the claim status as being forwarded. It is our understanding that the applicable status of either the Host plan or the Home plan would be reported (rather than transferred), depending on where the claim is within the combined Blues’ processing cycle.

Status code 16 is generally used when payer A (or another entity who received the claim) has forwarded it to Payer B and Payer A is no longer responsible for the claim. Status code 16 is essentially telling the requester that all future requests should go to Payer B. In this situation, the workgroup recommends the Entity code IN – Insurer or in the case of a COB claim, PRP – Primary Payer, SEP – Secondary Payer or TTP – Tertiary Payer.